drug name cpt dosage covered diagnosis code

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Do not duplicate or distribute

Use and distribution limited solely to authorized personnel

© Copyright 2012 (CGS Administrators, LLC)

Drug Name CPT

Code

Dosage Covered Diagnosis

Aldesleukin; Proleukin,

Interleukin II (IL-2)

J9015 per single

use vial

172.0 - 172.9; 189.0; 189.1;

205.00 - 205.92

Bendamustine

hydrochloride;

Treanda

J9033 200.10 - 200.18; 200.30 - 200.38;

200.40 - 200.48; 202.00 - 202.08;

202.80 - 202.88; 203.00; 203.02;

203.10; 203.80; 204.10; 204.11;

204.12; 238.6; 273.3

Bevacizumab;

Avastin

J9035

10mg

153.0 - 153.9; 154.0 - 154.1;

154.8; 158.0 - 158.9; 162.2 -

162.9; 174.0 - 174.9; 175.0 -

175.9; 183.0; 183.2 - 183.5;

183.8- 183.9; 189.0 - 189.1;

191.0 - 191.9; 197.0; 197.7;

198.0

Cabazitaxel;

Jevtana

J3490

or

J9999

185





Carboplatin J9045 50mg 140.4; 140.5; 140.6; 140.8;

140.9; 141.0 - 141.6; 141.8 -

141.9; 142.0 - 142.2; 142.8 -

142.9; 143.0; 143.1; 143.8;

143.9; 144.0; 144.1; 144.8;

144.9; 145.0 - 145.6; 145.8;

145.9; 146.0 - 146.9; 147.0 -

147.3; 147.8; 147.9; 148.0 -

148.3; 148.8; 148.9; 149.0;

149.1; 149.8; 149.9; 150.0 -

150.5; 150.8; 150.9; 151.0 -

151.6; 151.8; 151.9; 158.8;

158.9; 160.0 - 160.5; 160.8;

160.9; 161.0 - 161.3; 161.8;

161.9; 162.0; 162.2 - 162.5;

162.8; 162.9; 163.0; 163.1;

163.8; 163.9; 164.0; 170.0 -

170.9; 172.0 - 172.9; 173.00 -

173.99; 174.0 - 174.6; 174.8;

174.9; 175.0; 175.9; 180.0;

180.1; 180.8; 180.9; 182.0;

183.0; 183.2 - 183.5; 183.8;

183.9; 185; 186.0; 186.9; 188.0 -

188.9; 189.0 - 189.2; 190.5;

190.6; 191.0 - 191.9; 192.8;

192.9; 194.0; 194.1; 194.3 -

194.6; 194.8; 194.9; 195.0;

199.1; 200.00- 200.08; 200.10 -

200.18; 200.20 - 200.28; 200.30 -

200.38; 200.40 - 200.48; 200.50 -

200.58; 200.60 - 200.68; 200.70 -

200.78; 200.80 - 200.88; 201.00 -

201.08; 201.10 - 201.18; 201.20 -

201.28; 201.40 - 201.48; 201.50 -

201.58; 201.60 - 201.68;

201.70 - 201.78; 201.90 - 201.98;

202.00 - 202.08; 202.10 - 202.18;

202.20 - 202.28; 202.30 - 202.38;

202.40 - 202.48; 202.50 - 202.58;

202.60 - 202.68; 202.70 - 202.78;

202.80 - 202.88; 202.90 - 202.98;

204.00 - 204.12; 204.20 - 204.22;

204.80 - 204.82; 204.90 - 204.92;

205.00 - 205.02; 205.10 - 205.12;

205.20 - 205.22; 205.30 - 205.32;

205.80 - 205.82; 205.90 - 205.92;

206.00 - 206.02; 206.10 - 206.12;

206.20 - 206.22; 206.80 - 206.82;

206.90 - 206.92; 207.00 - 207.02;

207.10 - 207.12; 207.20 - 207.22;





207.80 - 207.82; 208.00 - 208.02;

208.10 - 208.12; 208.20 - 208.22;

208.80 - 208.82; 208.90 - 208.92;

209.30 - 209.36; 209.75; 212.6;

233.7; 235.1; 235.5; 235.6;

237.5; 239.0 - 239.2; 239.6;

239.89; 239.9; V10.11; V10.29;b

V10.3; V10.46; V10.51; V10.88;

V10.91





Capsaicin 8% patch

(Qutenza®)

Effective for

dates of service

on or after

01/01/2011, HCPCS

code J7335 should

be used to report

capsaicin 8% patch

(e.g., Qutenza®).

For services

billed to the Part

A MAC, HCPCS code

C9268 should be

used to report

capsaicin 8% patch

(e.g., Qutenza®)

effective for

dates of service

on or after

07/01/2010 through

12/31/2010.

J7335 053.19

Cetuximab; Erbitux J9055 10mg 140.0 - 149.9; 153.0 - 153.9;

154.0; 154.1; 154.8; 160.0 -

161.9; 162.0; 162.2 - 162.5;

162.8; 162.9; 170.0; 171.0;

173.00-173.02; 173.09; 173.4;

195.0; 230.0; 232.0; 232.3; 232.4

235.1; 235.6

Decitabine;

DACOGEN

J0894 1mg 205.00 - 205.02; 205.10 - 205.12;

205.80 - 205.82; 205.90 - 205.92;

238.72 - 238.77

Denileukin

Diftitox; Ontak

Limitations:

Prior to the

administration of

denileukin

difitox, the

patient≤s malignant

cells should be

tested for CD25

J9160 300mcg 200.60 - 200.68; 202.10 - 202.18;

202.20 - 202.28; 202.70 – 202.78;

202.80 - 202.81; 202.84; 202.85;

202.88; 204.00- 204.92





expression

Denosumab (Prolia,

Xgeva)

For

dates

of

service

01/01/2

012 and

forward

:

96372

J0897

Part A

only

C9399

For

dates

of

service

12/31/2

011 and

prior:

96372

C9272

C9399

J3590

For the treatment of patients

with bone metastases from solid

tumors correct coding requires

that a bone metastasis diagnosis

be present on the claim as the

primary diagnosis and the

original cancer or history of

cancer be included as the

secondary diagnosis. The claim

must include ICD.9 code 198.5

plus the ICD.9 code for the

patient’s original cancer or

history of cancer.

For treatment to increase bone

mass in women at high risk for

fracture receiving adjuvant

aromatase inhibitor therapy for

breast cancer. The clinical

documentation must clearly

support this use and the claim

must include both ICD-9 code

733.09 plus an ICD-9 code from

one of the following ranges:

174.0-174.9,

175.0-175.9

For treatment to increase bone

mass in men at high risk for

fracture receiving androgen

deprivation therapy for

nonmetastatic prostate cancer

The clinical documentation must

clearly support this use and the

claim must include both ICD-9

codes 733.09 plus 185

For the treatment of

postmenopausal women with

osteoporosis at high risk for

fracture and women with

osteoporosis who have failed or

are intolerant to other available

osteoporosis therapy both a

primary and secondary diagnosis

must be reported: 733.01





Secondary Diagnosis

For Intolerance to Other

Available Osteoporosis Therapy:

585.3, 585.4, 585.5, 909.5,

V14.8, V87.49

For High Risk of Fracture:

345.10 – 345.11, 438.20 – 438.22,

438.40 – 438.42, 438.50 – 438.53,

438.84 - 438.85, 438.9,

733.10 -733.16,

733.19,

780.31 – 780.32, 780.39, 781.2,

781.3, V49.89

Docetaxel;

Taxotere

J9171 1mg 140.0 - 149.9; 150.0 - 150.9;

151.0 - 151.9; 157.0 - 157.9;

158.0; 158.8; 158.9; 160.0 -

160.9; 161.0 - 161.9; 162.0;

162.2 - 162.5; 162.8; 162.9;

170.0 - 170.9; 171.0 - 171.3;

171.5; 171.8; 171.9; 172.0 -

172.9; 173.00-173.02; 173.09;

173.20-173.22; 173.29; 173.30-

173.32; 173.39; 173.40 -173.42;

173.49; 174.0 - 174.9; 175.0 -

175.9; 176.0 - 176.9; 179; 180.0

- 180.9; 182.0; 182.1; 182.8;

183.0; 183.2; 183.3 - 183.5;

183.8; 183.9; 185; 188.0 - 188.9;

189.1 - 189.3; 189.8; 189.9;

190.0 - 190.9; 191.0 - 191.9;

192.0 - 192.1; 193; 194.1

194.5; 195.0; 199.0; 199.1;

209.70 - 209.79; 233.7; 235.1;

235.2; 235.5; 235.6; 238.1; 239.0

- 239.2; 239.6; 239.81 239.89;

239.9

Doxorubicin

Doxorubician

Hydrochoride

J9000 10mg 140.0 - 140.1; 140.3 - 140.6;

140.8; 140.9; 141.0 - 141.6

141.8; 141.9; 142.0 - 142.2;

142.8; 142.9; 143.0; 143.1;

143.8; 143.9; 144.0; 144.1;

144.8; 144.9; 145.0 - 145.6;

145.8; 145.9; 146.0 - 146.9;

147.0 - 147.3; 147.8; 147.9;





148.0 - 148.3; 148.8; 148.9;

149.0 - 149.1; 149.8; 149.9;

150.0 - 150.5; 150.8 - 150.9;

151.0 - 151.6; 151.8; 151.9;

152.0 - 152.3; 152.8; 152.9;

153.0 - 153.9; 155.0 - 155.2;

156.0 - 156.2; 156.8; 156.9;

157.0 - 157.4; 157.8; 157.9;

158.0; 158.8 - 158.9; 160.0 -

160.5; 160.8; 160.9; 161.0 -

161.3; 161.8; 161.9; 162.0; 162.2

- 162.5; 162.8 - 162.9; 164.0;

164.8; 170.0 - 170.9; 171.0;

171.2 - 171.9; 173.00 -

173.99; 174.0 - 174.6; 174.8;

174.9; 175.0; 175.9; 176.0 -

176.5; 176.8; 176.9; 179; 180.0;

180.1; 180.8; 180.9; 181;

182.0; 183.0; 183.2; 183.9;

184.0; 185; 186.0; 186.9; 188.0 -

188.9; 189.0 - 189.2; 190.5; 193;

194.0; 194.1; 194.3 - 194.6;

194.8; 194.9; 195.0; 197.6;

198.5; 200.00 - 200.08; 200.10 -

200.18; 200.20 - 200.28; 200.30 -

200.38; 200.40 - 200.48; 200.50 -

200.58; 200.60 - 200.68; 200.70 -

200.78; 200.80 - 200.88; 201.00 -

201.08; 201.10 - 201.18; 201.20 -

201.28; 201.40 - 201.48 - 201.58;

201.60 - 201.68; 201.70 - 201.78

; 201.90 - 201.98; 202.00 -

202.08; 202.10 - 202.18; 202.20 -

202.28; 202.30 - 202.38: 202.40 -

202.48; 202.50 - 202.58; 202.60 -

202.68; 202.70 - 202.78; 202.80 -

202.88; 202.90 - 202.98; 203.00 -

203.02; 204.00 - 204.02; 204.10 -

204.12; 205.00 - 205.02; 205.10 -

205.12; 205.20 - 205.22; 205.30 -

205.32; 205.80 - 205.82; 205.90 -

205.92; 206.00 - 206.02; 207.00 -

207.02; 209.00 - 209.02; 209.03;

209.10 - 209.17; 209.20 - 209.27;

209.29; 209.30; 209.36; 209.40 -

209.43; 209.50 - 209.57; 209.60 -

209.67; 209.69; 209.79; 211.7;

212.6; 233.7; 236.1; 238.1;

238.6; 239.2; 259.2; 998.9;

V10.90; V10.91; V23.89





Doxorubicin,

Liposomal; Doxil,

Caelyx

Doxorubicin

hydrochloride, all

lipid formulations

J9001 10mg 158.0; 158.8; 158.9; 170.0 -

170.9; 171.0; 171.2; 171.3;

171.5; 171.8; 171.9; 174.0 -

174.9; 175.0 - 175.9; 176.0 -

176.9; 182.0 - 182.8; 183.0;

183.2 - 183.5; 183.8; 183.9;

197.6; 201.40 - 201.48; 201.50 -

201.58; 201.60 - 201.68; 201.70

201.78; 201.90 - 201.98; 202.10 -

202.18; 202.20 - 202.28; 203.00 -

203.02; 203.10; 203.80

209.00 - 209.36; 209.70 - 209.79;

238.1; 238.6

Eculizumab;

Soliris

J1300 300mg 283.2;283.11

Epirubicin;

Epirubicin HC1

J9178 2mg 147.0 - 147.3; 147.8; 147.9;

150.0 - 150.5; 150.8; 150.9;

151.0 - 151.6; 151.8 - 151.9;

158.0; 158.8; 158.9; 162.2 -

162.5; 162.8; 162.9l 170.0 -

170.9; 171.0; 171.2 - 171.9;

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 183.0; 183.2 -

183.5; 183.8; 183.9; 188.0 -

188.9; 200.00 - 200.08; 200.10 -

200.18; 200.20 - 200.28; 200.30 -

200.38; 200.40 - 200.48; 200.50 -

200.58; 200.60 - 200.68; 200.70 -

200.78; 200.80 - 200.88; 201.00 -

201.08; 201.10 - 201.18; 201.20 -

201.28; 201.40 - 201.48; 201.50 -

201.58; 201.60 - 201.68; 201.70 -

201.78; 201.90 - 201.98; 202.00 -

202.08; 202.10 - 202.18; 202.20 -

202.28; 202.30 - 202.38; 202.40 -

202.48; 202.50 - 202.58; 202.60 -

202.68; 202.70 - 202.78; 202.80 -

202.88; 202.90 - 202.98; 209.31 -

209.36; 209.75; 235.2; 235.5;

238.1

Eribulin Mesylate;

Halaven

Halaven Injection

For

dates

of

service

174.0-175.9





01/01/2

012 and

forward

:

J3490

J3590

J9179

For

dates

of

service

12/31/2

011 and

prior:

J3490,

J3590,

J9999

Etoposide

Limitations:

for AIDS re;ated

B-cell lymphoma,

ICD-9-CM code 042

should be reported

in addition to

ICD.9-CM codes

200.20-200.28,

200.70-200.78,

200.80-200.88, and

202.80-202.88.

J9181 10mg 151.0 - 151.6; 151.8; 151.9;

155.0; 155.2; 158.8; 158.9; 160.0

- 160.5; 160.8; 160.9; 162.0;

162.2 - 162.5; 162.8; 162.9;

164.0; 164.8; 170.0 - 170.9;

171.0 - 171.9; 173.00 - 173.99;

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 176.0 - 176.5;

176.8; 176.9; 181; 182.0; 182.1;

182.8; 183.0; 183.2 - 183.5;

183.8; 183.9; 185; 186.0; 186.9;

188.0 - 188.9; 189.0; 190.5;

191.0 - 191.9; 192.8; 194.0;

194.1; 194.3 - 194.6; 194.8;

194.9; 199.1; 200.00 - 200.08;

200.10 - 200.18; 200.20 - 200.28;

200.30 - 200.38; 200.40 - 200.48;

200.50 - 200.58; 200.60 - 200.68;

200.70 - 200.78; 200.80 - 200.88;

201.00 - 201.08; 201.10 - 201.18;

201.20 - 201.28; 201.40 - 201.48;

201.50 - 201.58; 201.60 - 201.68;

201.70 - 201.78; 201.90 - 201.98;

202.00 - 202.08; 202.10 - 202.18;

202.20 - 202.28; 202.30 - 202.38;

202.40 - 202.48; 202.50 - 202.58;

202.60 - 202.68; 202.70 - 202.78;

202.80 - 202.88; 202.90 - 202.98;

203.00 - 203.02; 203.10; 203.12;

203.80; 203.82; 204.00 - 204.02;

204.10; 204.12; 204.90; 204.92;





205.00 - 205.02; 205.10 - 205.12;

206.00 - 206.02; 207.00 - 207.02;

209.21; 209.30 - 209.36; 212.6;

212.8; 236.1; 237.5; 238.1;

238.6; 238.71 - 238.77; 238.79;

239.0 - 239.2; 239.6; 239.89;

239.9; V10.11; V10.29; V10.3;

V10.46; V10.81; V10.85; V10.88;

V10.91; V49.83

Floxuridine J9200 500mg 151.0 - 151.6; 151.8; 151.9;

153.0 - 153.9; 154.0 - 154.3;

154.8; 155.0 - 155.2; 183.0;

183.2; 183.8; 183.9; 189.0; 189.1

Fluocinolone

acetonide

intravitreal

implant

* Code ICD-9-CM

code 363.13 first

with any

underlying disease

J7311 360.11; 360.12; 362.18; 363.00;

363.10; 363.12; 363.13; 363.20;

363.21

Gemcitabine

Gemzar,

Gemcitabine

hydrochloride

J9201 200mg 147.0 - 147.3; 147.8; 147.9;

149.0; 149.1; 149.9; 155.1; 156.0

- 156.2; 156.8; 156.9; 157.0 -

157.4; 157.8; 157.9; 158.0;

158.8; 158.9; 162.0; 162.2 -

162.5; 162.8; 162.9; 163.0;

163.1; 163.8; 163.9; 164.0;

164.2; 164.3; 164.8; 164.9; 170.0

- 170.9; 171.0; 171.2 - 171.9;

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 176.0 - 176.5;

176.8; 176.9; 179; 180.0; 180.1;

180.8; 180.9; 181; 182.0; 182.1;

182.8; 183.0; 183.2 - 183.5;

183.8; 183.9; 185; 186.0; 186.9;

188.0 - 188.9; 189.0 - 189.2;

194.4; 195.0 - 195.5; 195.8;

199.0; 199.1; 200.00 - 200.08;

200.10 - 200.18; 200.20 - 200.28;

200.30 - 200.38; 200.40 - 200.48;

200.50 - 200.58; 200.60 - 200.68;

200.70 - 200.78; 200.80 - 200.88;

201.00 - 201.08; 201.10 - 201.18;

201.20 - 201.28; 201.40 - 201.48;





201.50 - 201.58; 201.60 - 201.68;

201.70 - 201.78; 201.90 - 201.98;

202.00 – 202.08; 202.10- 202.18;

202.20 - 202.28; 202.30 - 202.38;

202.40 - 202.48; 202.50 - 202.58;

202.60 - 202.68; 202.70 - 202.78;

202.80 - 202.88; 202.90 - 202.98;

209.30; 212.6; 233.7; 235.1;

238.1; 239.0 - 239.2; 239.6;

239.89; 239.9; V10.02; V10.07;

V10.09; V10.11; V10.12; V10.20;

V10.29; V10.3; V10.42 - V10.44;

V10.47; V10.51 - V10.53; V10.59;

V10.71; V10.72; V10.79; V10.81;

V10.83; V10.88; V10.89

Gemtuzumab

Ozogamicin;

Mylotarg

J9300 5mg 205.00 - 205.02

Goserelin Acetate

Implant

Limitations:

The ICD-9-CM codes

listed with an

asterisk (*) are

considered

secondary codes.

When these codes

are reported for

J9202, the claim

must also include

a diagnosis from

the primary

diagnosis list.

J9202 per 3.6

mg

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 185; 196.2*;

196.5*; 196.8*; 196.9*; 197.0*;

197.6*; 197.7*; 198.2*; 198.3*;

198.5*; 218.0 - 218.2; 218.9;

233.4; 617.0 - 617.6; 617.8;

617.9; 626.8; V10.3; V10.46

Ifosfamide

NOTE:

for AIDS related

B-cell lymphoma,

ICD-9-CM code 042

should be reported

in addition to

ICD-9-CM codes

200.20-200.28 and

200.80-200.88

J9208 1 gram 140.0; 140.1; 140.3 - 140.6;

140.8; 140.9; 141.0 - 141.6;

141.8; 141.9; 142.0 - 142.2;

142.8; 142.9; 143.0; 143.1;

143.8; 143.9; 144.0; 144.1;

144.8; 144.9; 145.0 - 145.6;

145.8; 145.9; 146.0 - 146.9;

147.0 - 147.3; 147.8; 147.9;

148.0 - 148.3; 148.8; 148.9;

149.0; 149.1; 149.8; 149.9; 155.0

- 155.2; 157.0 - 157.4; 157.8;

157.9; 158.0; 158.8; 158.9; 160.0

- 160.5; 160.8; 160.9; 161.0 -





161.3; 161.8; 161.9; 162.0; 162.2

- 162.5; 162.8; 162.9; 164.0;

164.8; 170.0 - 170.9; 171.0;

171.2 - 171.9; 173.00-173.99;

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 179; 180.0 ; 180.1;

180.8; 180.9; 182.0; 182.1;

182.8; 183.0; 183.2 - 183.5;

183.8; 183.9; 186.0; 186.9; 188.0

- 188.9; 189.0 - 189.2; 195.0;

200.00 - 200.08; 200.10 - 200.18;

200.20 - 200.28; 200.30 - 200.38;

200.40 - 200.48; 200.50 - 200.58;

200.60 - 200.68; 200.70 - 200.78;

200.80 - 200.88; 201.00 - 201.08;

201.10 - 201.18; 201.20 - 201.28;

201.40 - 201.48; 201.50 - 201.58;

201.60 - 201.68; 201.70 - 201.78;

201.90 - 201.98; 202.00 - 202.08;

202.10 - 202.18; 202.20 - 202.28;

202.30 - 202.38; 202.40 -202.48;

202.50 - 202.58; 202.60 - 202.68;

202.70 - 202.78; 202.80 - 202.88;

202.90 - 202.98; 203.00; 203.02;

204.00; 204.02; 209.30; 212.6;

219.8; 233.7; 235.1; 235.6; 238.1

Iron Sucrose, Iron

Dextran and

Ferumoxytol,

(Intravenous Iron

Therapy)

J1750

J1756

J3490

Q0138

Q0139

Part A

For

dates

of

service

01/01/2

012 and

forward

use

J1756

For

dates

of

service

12/31/2

011 and

One of the primary diagnoses AND

one of the secondary diagnoses

listed with an asterisk (*) are

required for payment of iron

sucrose or iron dextran or

ferumoxytol.





prior

use

C9399

For patients with iron deficiency

anemia who do not respond to oral

iron supplementation due to

malabsorption disorders or

patients who have documented

intolerance to oral iron

supplementation.

280.0; 280.8; 280.9; 579.3*;

579.9*; 648.23; 995.29*; V12.79*

For anemia related to chronic

kidney disease:

280.0*; 280.1*; 280.8* 280.9*;

285.21*: 585.3 - 585.6

Initial treatment of absolute

iron deficiency in patients

receiving myelosuppressive

chemotherapy who have

asymptomatic anemia and risk

factors for the development of

symptomatic anemia requiring

transfusion:

285.22; V58.11*: V66.2*





For patients with anemia related

to chemotherapy, claims must be

reported with ICD-9-CM code 285.3

(antineoplastic chemotherapy

induced anemia) related to

chemotherapy plus the non-myeloid

malignancy for which the

chemotherapy was administered.

(Note: 205.00-205.91, 206.00-

206.91, 207.00-208.91 are myeloid

malignancies and are excluded

from coverage.)

140.0; 140.1; 140.3 - 140.6;

140.8; 140.9; 141.0 - 141.6:

141.8; 141.9; 142.0 - 142.2;

142.8; 142.9; 143.0; 143.1;

143.8; 143.9; 144.0; 144.1;

144.8; 144.9; 145.0; 145.1 -

145.6; 145.8; 145.9; 146.0 -

146.9; 147.0 - 147.3; 147.8;

147.9; 148.0 - 148.3; 148.8;

148.9; 149.0: 149.1; 149.8;

149.9; 150.0 - 150.5; 150.8;

150.9; 151.0 - 151.6; 151.8;

151.9; 152.0 - 152.3; 152.8;

152.9; 153.0 -153.9; 154.0 -

154.3; 154.8; 155.0 - 155.2;

156.0 - 156.2; 156.8; 156.9;

157.0 - 157.4; 157.8; 157.9;

158.0; 158.8; 158.9; 159.0;

159.1; 159.8; 159.9; 160.0 -

160.5; 160.8; 160.9; 161.0 -

161.3; 161.8; 161.9; 162.0; 162.2

- 162.5; 162.8; 162.9; 163.0;

163.1; 163.8; 163.9; 164.0 -

164.3; 164.8; 164.9; 165.0;

165.8; 165.9; 170.0 - 170.9;

171.0; 171.2 - 171.9; 172.0 -

172.9; 173.00 - 173.99; 174.0 -

174.9; 175.0; 175.9; 176.0 -

176.5; 176.8; 176.9; 179; 180.0;

180.1; 180.8; 180.9; 181; 182.0;

182.1; 182.8; 183.0; 183.2 -

183.5; 183.8; 183.9; 184.0 -

184.4; 184.8; 184.9; 185; 186.0;

186.9; 187.1; 187.2; 187.3 -

187.9; 188.0 - 188.9; 189.0 -

189.4; 189.8 - 189.9; 190.0 -

190.9; 191.0 - 191.9; 192.0 -





192.3; 192.8; 192.9; 193; 194.0;

194.1; 194.3 - 194.6; 194.8;

194.9; 195.0 - 195.5; 195.8;

196.0 - 196.6;

196.8; 196.9; 197.0 - 197.8;

198.0 - 198.7; 198.81; 198.82;

198.89; 199.0; 199.1; 200.00 -

200.08; 200.10 - 200.18; 200.20 -

200.28; 200.30 - 200.38; 200.40 -

200.48; 200.50 - 200.58; 200.60 -

200.68; 200.70 - 200.78; 200.80 -

200.88; 201.00 - 201.08; 201.10 -

201.18; 201.20 - 201.28; 201.40 -

201.48; 201.50 - 201.58; 201.60 -

201.68; 201.70 - 201.78; 201.90 -

201.98; 202.00 - 202.08; 202.10 -

202.18; 202.20 - 202.28; 202.30 -

202.38; 202.40 - 202.48; 202.50 -

202.58; 202.60 - 202.68; 202.70 -

202.78; 202.80 - 202.88; 202.90 -

202.98; 203.00 - 203.02; 203.10 -

203.12; 203.80 - 203.82; 204.00 -

204.02; 204.10 - 204.12; 204.20 -

204.22; 204.80 - 204.82; 204.90 -

204.92; 233.30 - 233.32; 233.39;

235.0 - 235.9

236.0 - 236.7; 236.90; 236.91;

236.99; 237.0 - 237.6; 237.70 -

237.72; 237.9; 238.0 - 238.3;

238.5; 238.6; 238.71 - 238.79;

238.8; 238.9; 239.0 - 239.7;

239.81;

239.89; 239.9; 273.3

Infliximab;

Remicade

J1745 10mg 135; 446.4; 555.0 - 555.9; 556.0

- 556.9; 565.1; 569.81; 696.0 -

696.1; 710.3 - 710.4; 714.0 -

714.2; 720.0; 733.99

Irinotecan

NOTE:

Irinotecan is

approved for the

treatment of

metastatic

malignancy.

Correct Coding

requires the use

J9206 20mg 150.0 - 150.5; 150.8; 150.9;

151.0 - 151.6; 151.8; 151.9;

152.0 - 152.3; 152.8; 152.9;

153.0 - 153.9; 154.0 - 154.3;

154.8; 157.0 - 157.4; 157.8;

157.9; 158.8; 162.0; 162.2 -

162.5; 162.8; 162.9; 170.0 -

170.9; 174.0 - 174.6; 174.8;

174.9; 175.0; 175.9; 180.0;

180.1; 180.8; 180.9; 183.0; 183.2





of the secondary

cancer code (196,

197, 198 and 199

series of ICD-9-CM

codes) as the

primary diagnosis

and the original

cancer site as the

secondary

diagnosis.

- 183.5; 183.8; 183.9; 191.0 -

191.9; 192.8; 202.80 - 202.88;

204.00; 205.00; 209.30

Ixabepilone;

Ixempra Injection

J9207 174.0-174.9; 175.0-175.9

Leuprolide Acetate

(for depot

suspension),

J1950 per

3.75mg

174.0 - 174.6; 174.8; 174.9;

175.0; 175.9; 218.0 - 218.2;

218.9; 617.0 - 617.6; 617.8;

617.9; V10.3

Leuprolide Acetate

(for depot

suspension)

Primary ICD-9-CM

codes (these

diagnoses can be

billed as a single

diagnosis or in

conjunction with

the secondary ICD-

9-CM codes listed

with an asterisk

(*)

The ICD-9-CM codes

listed with an

asterisk (*)are

considered

secondary codes.

When these codes

are reported for

J9217, the claim

must also include

a primary

diagnosis

J9217 Per

7.5mg

183.0; 185; 196.2*; 196.5*;

196.8*; 196.9*; 197.0*; 197.6*;

197.7*; 198.2*; 198.3*; 198.5*;

233.4; V10.3; V10.46

Leuprolide acetate

implant; Lupron

implant

J9219 65mg 185; 196.2*; 196.5*; 196.8*;

196.9*; 197.0*; 197.6*; 197.7*;

198.2*; 198.3*; 198.5*; 233.4;





The ICD-9-CM codes

listed with an

asterisk(*) are

considered

secondary codes.

When these codes

are reported for

J9219, the claim

must also include

a diagnosis from

the primary

diagnosis list.

V10.46

Mitomycin J9280 5mg 140.0; 140.1; 140.3 - 140.6;

140.8; 140.9; 141.0 - 141.6;

141.8; 141.9; 142.0 - 142.2;

142.8; 142.9; 143.0 - 143.1;

143.8; 143.9; 144.0; 144.1;

144.8; 144.9; 145.0 - 145.6;

145.8; 145.9; 146.0 - 146.9;

147.0 - 147.3; 147.8; 147.9;

148.0 - 148.9; 149.0; 149.1;

149.8; 149.9; 150.0 - 150.5;

150.8; 150.9; 151.0 - 151.6;

151.8; 151.9; 153.0 - 153.9:

154.0 - 154.3; 154.8; 155.0 -

155.2; 156.0 - 156.2; 156.8 -

156.9; 157.0 - 157.4; 157.8 -

157.9; 158.0; 158.8; 158.9; 160.0

- 160.5; 160.8; 160.9; 161.0 -

161.3; 161.8; 161.9; 162.0; 162.2

- 162.5; 162.8; 162.9; 163.0;

163.1; 163.8; 163.9; 164.0 -

164.3; 164.8; 164.9; 171.0; 171.2

- 171.9; 174.0 - 174.6; 174.8;

174.9; 175.0; 175.9; 180.0 -

180.1; 180.8; 180.9; 185; 188.0 -

188.9; 189.1; 189.2; 195.0;

205.10; 205.11; 205.12; 233.7;

V10.05; V10.3; V49.83

Ofatumumab;

Arzerra

J9302 200.10 - 200.18; 204.10-204.12

Oxaliplatin; J9263 0.5mg 150.0 - 150.9; 151.0 - 151.9;





Eloxatin 152.0 - 152.9; 153.0 - 153.9;

154.0; 154.1; 154.8; 155.1; 156.0

- 156.9; 157.0 - 157.3; 157.8;

157.9; 158.8; 162.0

162.9; 174.2 - 174.9; 175.0:

175.9; 183.0 - 183.9; 186.0;

186.9; 200.11 - 200.18; 200.30 -

200.38: 200.40 - 200.48; 200.60 -

200.68; 200.70 - 200.78; 202.01 -

202.08; 202.80

- 202.88; 202.90- 202.98;

204.10; 204.12; 235.2; 235.5

Paclitaxel; Taxol J9265 30mg 140.0 - 149.9; 150.0 - 151.9;

154.2; 154.3; 158.0; 158.8;

158.9; 160.0 - 162.9; 164.0;

171.0 - 174.9; 175.0; 175.9;

176.0 - 176.9; 179; 180.0 -

183.9; 185; 186.0; 186.9; 188.0 -

188.9; 189.1; 189.2; 191.0 -

191.9; 195.0; 199.1; 200.80 -

200.88; 202.70 - 202.98; 203.00;

203.01; 203.02; 209.30; 212.6;

233.7; 235.1; 235.6; 239.0 -

239.9; V10.11; V10.12; V10.29;

V10.3; V10.51

Paclitaxel

protein-bound

particles;

Abraxane

J9264 may be used

when the patient

has demonstrated

significant

intolerance to

standard

paclitaxel (J9265)

J9264 1mg 140.0 - 149.9; 154.2; 154.3;

157.0 - 157.9; 158.0; 158.8;

158.9; 162.0 - 162.9; 172.0-

172.9; 174.0 - 174.9; 175.0 -

175.9; 183.0 - 183.9; 195.0;

209.70 - 209.79

Pamidronate

Disodium; Aredia

J2430 30mg Paget’s Disease, Osteogenesis

Imperfecta, Senile Osteoporosis,

Complex regional pain syndrome,

type l:

337.20-337.22;337.29;731.0;

733.01; 756.51

Osteolytic lesions of multiple





myeloma:

203.00-203.02

Glucocorticoid-induced

osteoporosis:

Primary: 733.09

Secondary: V58.65;V58.69

Osteopenia – Quadriplegic

cerebral palsy:

Primary: 733.90

Secondary: 343.2

Osteolytic bone metastasis of

breast cancer:

Primary: 198.5

Secondary: 162.0;162.2-

162.5;162.8-162.9;174.0-

174.6;174.8-

174.9;175.0;175.9;185;209.21;V10.

11-V10.12;V10.3;V10.46

Moderate or severe hypercalcemia

associated with malignancy,

including Tamoxifen induced tumor

flare:

Primary: 275.42

Secondary: 140.0-140.1;140.3-

140.6;140.8-140.9;141.0-

141.6;141.8-141.9;142.0-

142.2;142.8-142.9;143.0-

143.1;143.8-143.9;144.0-

144.1;144.8-144.9;145.0-

145.6;145.8-145.9;146.0-

146.9;147.0-147.3;147.8-

147.9;148.0-148.3;148.8-

148.9;149.0-149.1;149.8-

149.9;150.0-150.5;150.8-

150.9;151.0-151.6;151.8-

151.9;152.0-152.3;152.8-

152.9;153.0-153.9;154.0-

154.3;154.8;155.0-155.2;156.0-

156.2;156.8-156.9;157.0-

157.4;157.8-157.9;158.0;158.8-

158.9;159.0-159.1;159.8-

159.9;160.0-160.5;160.8-

160.9;161.0-161.3;161.8-

161.9;162.0;162.2-162.5;162.8-

162.9;163.0-163.1;163.8-

163.9;164.0-164.3;164.8-





164.9;165.0;165.8-165.9;170.0-

170.9;171.0;171.2-171.9;172.0-

172.9;173.0-173.9;174.0-

174.6;174.8-

174.9;175.0;175.9;176.0-

176.5;176.8-176.9;179;180.0-

180.1;180.8-180.9;181;182.0-

182.1;182.8;183.0;183.2-

183.5;183.8-183.9;184.0-

184.4;184.8-

184.9;185;186.0;186.9;187.1-

187.9;188.0-188.9;189.0-

189.4;189.8-189.9;190.0;190.1-

190.9;191.0-191.9;192.0-

192.3;192.8-192.9;193;194.0-

194.1;194.3-194.6;194.8-

194.9;195.0-195.5;195.8;196.0-

196.3;196.5-196.6;196.8-

196.9;197.0-197.8;198.0-

198.7;198.81-198.82;198.89;199.0-

199.1;200.00-200.08;200.10-

200.18;200.20-200.28;200.30-

200.38;200.40-200.48;200.50-

200.58;200.60-200.68;200.70-

200.78;200.80-200.88;201.00-

201.08;201.10-201.18;201.20-

201.28;201.40-201.48;201.50-

201.58;201.60-201.68;201.70-

201.78;201.90-201.98,202.00-

202.08;202.10-202.18;202.20-

202.28;202.30-202.38;202.40-

202.48;202.50-202.58;202.60-

202.68;202.70-202.78;202.80-

202.88;202.90-202.98;203.00-

203.02;203.10-203.12;203.80-

203.82;204.00-204.02;204.10-

204.12;204.20-204.22;204.80-

204.82;204.90-204.92;205.00-

205.02;205.10-205.12;205.20-

205.22;205.30-205.32;205.80-

208.82;205.90-205.92;206.00-

206.02;206.10-206.12;206.20-

206.22;206.80-206.82;206.90-

206.92;207.00-207.02;207.10-

207.12;207.20-207.22;207.80-

207.82;208.11-208.12;208.20-

208.82;208.90-208.92;209.00-

209.03;209.10-209.17;209.20-

209.27;209.29-209.36;209.71-

209.75;209.79;211.7;238.6;259.2;





V10.00-V10.07;V10.09;V10.90-

V10.91

Panitumumab;

Vectibix

J9303 153.0 - 153.9; 154.0; 154.1;

154.8

Pemetrexed; Alimta J9305 10mg 158.8; 162.0; 162.2 - 162.9;

163.0 - 163.9; 164.0; 183.0 -

183.9; 188.0 - 188.9; 189.1;

189.2; 198.6, 212.6

Porfimer Sodium;

Photofrin

J9600 75mg 150.0 - 150.9; 162.2; 162.3;

162.4; 162.5; 162.8; 162.9

Pralatrexate;

Folotyn; Injection

J9307 1mg 200.60 - 200.68; 202.70 - 202.78;

202.80 - 202.88

Rituximab; Rituxan J9310 100mg 200.00 - 200.88; 201.00 - 201.98;

202.00 - 202.08; 202.40 - 202.48;

202.70 - 202.78; 202.80 - 202.88;

202.90 - 202.98; 204.10 - 204.12;

273.3; 283.0; 286.52; 286.53;

286.59; 287.30; 287.31 - 287.33;

287.39; 446.0; 446.4; 446.6;

585.6 714.0; 714.1; 714.2;

996.81; 996.88

Sodium Ferric

Gluconate,

(Intravenous Iron

Therapy)

J2916 One of the primary diagnoses AND

one of the secondary diagnoses

listed with an asterisk (*) are

required for payment of sodium

ferric gluconate.

• For patients with iron

deficiency anemia who do not

respond to oral iron

supplementation due to

malabsorption disorders or

patients who have documented

intolerance to oral iron

supplementation.

280.0; 280.8; 280.9; 579.3*;

579.9*; 648.23; 995.29*; V12.79*





• For anemia related to chronic

kidney disease:

280.0*; 280.1*; 280.8*; 280.9*;

285.21* 585.3 - 585.6

• Initial treatment of absolute

iron deficiency in patients

receiving myelosuppressive

chemotherapy who have

asymptomatic anemia and risk

factors for the development of

symptomatic anemia requiring

transfusion.

285.22; V58.11*; V66.2*

• For patients with anemia

related to chemotherapy, claims

must be reported with ICD-9-CM

code 285.3 (antineoplastic

chemotherapy induced anemia)

related to chemotherapy plus the

non-myeloid malignancy for which

the chemotherapy was

administered. (Note: 205.00-

205.91, 206.00-206.91, 207.00-

208.91 are myeloid malignancies

and are excluded from coverage.)

285.3

140.0* - 140.6*; 140.8*; 140.9*;

141.0* = 141.6*; 141.8*; 141.9*;

142.0* - 142.2*; 142.8*; 124.9*;

143.0*; 143.1*: 143.8*; 143.9*;

144.0*; 144.1*; 144.8*; 144.9

145.0* - 145.6*; 145.8*; 145.9*;





146.0* - 146.9*; 147.0* - 147.3*;

147.8*; 147.9*; 148.0* - 148.3*:

148.8*: 148.9*; 149.0*; 149.1*;

149.8*; 149.9*; 150.0* - 150.5*;

150.8*; 150.9*; 151.0* - 151.6*;

151.8*; 151.9*; 152.0* - 152.3*;

152.8*; 152.9*; 153.0* - 153.9*;

154.0* - 154.3*; 154.8*; 155.0* -

155.2*; 156.0* - 156.2*; 156.8*;

156.9*; 157.0* - 157.4*; 157.8*;

157.9*; 158.0*; 158.8*; 158.9*;

159.0*; 159.1*; 159.8*; 159.9*;

160.0* - 160.5*; 160.8*; 160.9*;

161.0* - 161.3*; 161.8* - 161.9*;

162.0*; 162.2* - 162.5*; 162.8*;

162.9*; 163.0*; 163.1*; 163.8*;

163.9*; 164.0* -164.3*; 164.8*;

164.9*; 165.0*; 165.8*; 165.9*;

170.0* - 170.9*; 171.0*; 171.2* -

171.9*; 172.0* - 172.9*; 173.0* -

173.9*; 174.0* - 174.6*; 174.8*;

174.9*; 175.0*; 175.9*; 176.0* -

176.5*; 176.8*; 176.9*; 179*;

180.0*; 180.1*; 180.8*; 180.9*;

181*; 182.0*; 182.1*; 182.8*;

183.0*; 183.2* - 183.5*; 183.8*;

183.9*; 184.0* - 184.4*; 184.8*;

184.9*; 185*; 186.0*; 186.9*;

187.1* - 187.9*; 188.0* - 188.9*;

189.0* - 189.4*; 189.8*; 189.9*;

190.0* - 190.9*; 191.0* - 191.9*;

192.0* - 192.3*; 192.8*; 192.9*;

193*; 194.0*;194.1*; 194.3* -

194.6*; 194.8*; 194.9*; 195.0* -

195.5*; 195.8*; 196.0* - 196.3*;

196.5*; 196.6*; 196.8*; 196.9*;

197.0* - 197.8*; 198.0* - 198.7*;

198.81*; 198.82*; 198.89*;

199.0*; 199.1*; 200.00* -

200.08*; 200.10* - 200.18*;

200.20* - 200.28*; 200.30* -

200.38*; 200.40* - 200.48*;

200.50* - 200.58*; 200.60* -

200.68*; 200.70* - 200.78*;

200.80* - 200.88*; 201.00* -

201.08* - 201.18*; 201.20* -

201.28*; 201.40* - 201.48*;

201.50* - 201.58*; 201.60* -

201.68*; 201.70* - 201.78*;

201.90* - 201.98*; 202.00* -





202.01; 202.02 - 202.08*;

202.10* - 202.18*; 202.20* -

202.28*; 202.30* - 202.38* ;

202.40* - 202.48*; 202.50* -

202.58*; 202.60* - 202.68*;

202.70* - 202.78*; 202.80* -

202.88*; 202.90* - 202.98*;

203.00* - 203.02*; 203.10* -

203.12*; 203.80* - 203.82*;

204.00* - 204.02*; 204.10* -

204.12*; 204.20* - 204.22*;

204.80* - 204.82*; 204.90* -

204.92*; 233.30* - 233.32*;

233.39*; 235.0* - 235.9*; 236.0*

- 236.7*; 236.90*; 236.91*;

236.99*; 237.0* - 237.6*; 237.70*

- 237.72*; 237.9*; 238.0* -

238.3*; 238.5*; 238.6*; 238.71-

238.79*; 238.8*; 238.9*; 239.0* -

239.7*; 239.81*; 239.89*; 239.9*;

273.3*; 280.0*; 280.1*; 280.8*;

280.9*; 585.3-585.6

Sipuleucel-T

Sipuleucel-

T;Provenge;

Injection

J3490

J3590

J9999

Q2043

Please refer to Article A51280

on the CMS MCD for complete

coverage guidelines.

Supply of

radiopharmaceutica

l diagnostic

imaging agent,

Indium-111;

Ibritumomab

A9543 Supply of

radiopharmaceutica

l therapeutic

imaging agent,

Yttrium 90

Ibritumomab

NOTE:

Zevalin use is

approved as part

of a therapeutic

regimen with

Rituximab.

Rituximab must be

administered on

the same date of

A9542

A9543

200.00 - 200.88; 202.00 -

202.08; 202.70 - 202.78; 202.80

- 202.88; 202.90 - 202.98





service as either

Indium-111

Ibritumomab or

Yttrium 90

Ibritumomab

Thyrotropin Alfa

(Thyrogen®)

J3240 193; 241.1; 244.0; V10.87

Topotecan;

Hycamtin

J9351 0.1mg 158.8; 158.9; 162.0; 162.2 -

162.5; 162.8; 162.9; 170.0 -

170.9; 173.00 - 173.99; 180.0 -

180.9; 182.0 - 182.8; 183.0;

183.2; 183.4; 183.5; 183.8;

183.9; 197.0; 197.3; 197.7;

198.3; 198.5; 198.7; 200.50 -

200.58; 205.10 - 205.12; 205.80 -

205.82; 209.00 - 209.36; 209.70 -

209.79; 219.0; 233.1; 236.0;

238.71 - 238.79; 239.2; 239.5

Trastuzumab;

Herceptin

J9355 10mg 150.0 - 150.9; 151.0 - 151.9;

174.0 - 174.9; 175.0 - 175.9;

235.2; 235.5; 238.3; 239.3; V10.3

Triptorelin

Pamoate

The ICD-9-CM codes

listed with an

asterisk(*) are

considered

secondary codes.

When these codes

are reported for

J3315, the claim

must also include

a primary

diagnosis fromthe

list.

J3315 3.75mg 185; 196.2*; 196.5*; 196.8*;

196.9*; 197.0*; 197.6*; 197.7*;

198.2*; 198.3*; 198.5*; 233.4;

V10.46

Vantas Implant

Histrelin implant

Limitations:

Use ICD-9-CM code

259.1 for children

J9225 50mg 185; 196.2*; 196.5*; 196.8*;

196.9*; 197.0*; 197.6*; 197.7*;

198.2*; 198.3*; 198.5*; 233.4;

V10.46





with disability

who are covered

under Medicare.

Primary ICD-9-CM

codes (these

diagnoses can be

billed as a single

diagnosis or in

conjunction with

the secondary ICD-

9-CM codes listed

with an asterisk

(*)

The ICD-9-CM codes

listed with an

asterisk (*) are

considered

secondary codes.

When these codes

are reported

J9225, the claim

must also include

a diagnosis from

the primary

diagnosis list.

Vantas Implant;

Supprelin LA

J9225 50mg 259.1

Vinorelbine

Tartrate

J9390 10mg 140.0; 140.1; 140.3 - 140.6;

140.8; 140.9; 141.0 - 141.6;

141.8; 141.9; 142.0 - 142.2;

142.8; 142.9; 143.0 - 143.1;

143.8; 143.9; 144.0 - 144.1;

144.8; 144.9; 145.0 - 145.6;

145.8; 145.9; 146.0 - 146.9;

147.0 - 147.3; 147.8 - 147.9;

148.0 - 148.3; 148.8; 148.9;

149.0 - 149.1; 149.8; 149.9;

150.0 - 150.5; 150.8; 150.9;

158.0; 158.8; 158.9; 162.0; 162.2

- 162.5; 162.8; 162.9; 171.0;

171.2 -171.9; 174.0 - 174.6;

174.8; 174.9; 175.0; 175.9; 176.0

- 176.5; 176.8; 176.9; 180.0;

180.1; 180.8; 180.9; 183.0; 183.2

-183.5;





183.8; 183.9; 185; 200.80 -

200.88; 201.00 - 201.08; 201.10 -

201.18; 201.20 - 201.28; 201.40 -

201.48; 201.50 - 201.58; 201.60 -

201.68; 201.70 - 201.78; 201.90 -

201.98; 202.70 - 202.78; 202.80 -

202.88; 202.90 - 202.98; V10.03;

V10.11; V10.3; V10.41; V10.43;

V10.44; V10.46

drug name cpt dosage covered diagnosis code

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